Provider Demographics
NPI:1821615113
Name:FOUNTAIN, SKYLER P
Entity Type:Individual
Prefix:
First Name:SKYLER
Middle Name:P
Last Name:FOUNTAIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:322 DEPOT AVE
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021-2850
Mailing Address - Country:US
Mailing Address - Phone:815-288-6057
Mailing Address - Fax:
Practice Address - Street 1:322 DEPOT AVE
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021-2850
Practice Address - Country:US
Practice Address - Phone:815-288-6057
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-02
Last Update Date:2020-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker